hs/ke/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz M. Almn / F / 65 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE with paresthesias since 2 months.

EXAMINATION :

M.R.I of the lumbo-sacral spine was performed using the following parameters :

5 mm thick T1 Weighted and T2 Weighted sagittal images.

5 mm thick T1 Weighted and T2 Weighted axial images.

OBSERVATION :

There is retroplacement of the L2 vertebra over the L3 vertebra.

A posterior disc herniation with peridiscal osteophytes is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level.

There is a small postero-central disc herniaton indenting the thecal sac at the L5-S1 level. A large left far lateral (extraforaminal) disc herniation is seen to indent the extraforaminal portion of the exiting left L5 nerve root at this level.

Bilateral postero-lateral (foraminal) disc herniations with peridiscal osteophytes are seen to narrow both neural foramina at the L2-L3 and L3-L4 levels.

The L4-L5 and L5-S1 facet joints show severe hypertrophic degenerative changes. Ligamentum flavum hypertrophy is also noted at these levels.
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Small far lateral (extraforaminal) disc herniations are seen bilaterally at the L4-L5 level and on the right side at the L5-S1 level. Bilateral far lateral (extraforaminal) disc bulges are noted at the L2-L3 and L3-L4 levels.

An anterior disc herniation with large peridiscal osteophytes is seen at the L3-L4 level. Anterior disc herniations are noted at the L1-L2 and L2-L3 levels.

The lumbar vertebral bodies show Type II degenerative changes.

The lumbar intervertebral discs show loss of water content.

Schmorls nodes are noted in the lumbar region.

The pedicles of the lumbar vertebrae appear to be congenitally short in their antero-posterior dimensions.

Posteriorly bulging discs are noted in the visualized lower dorsal region.

The paraspinal muscles in the lumbar region show atrophy.

The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1 level and the thecal sac terminates at the S2 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

15.0 mm at L1-L2
14.0 mm at L2-L3
12.0 mm at L3-L4
9.0 mm at L4-L5
8.0 mm at L5-S1.
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- 3 - Scan-00007


IMPRESSION :

The MRI features are suggestive of :

1. A posterior disc herniation with peridiscal osteophytes at the L4-L5 level.

2. A small postero-central disc herniaton at the L5-S1 level with a large left far lateral (extraforaminal) disc herniation indenting the extraforaminal portion of the exiting left L5 nerve root at this level.

4. Bilateral postero-lateral (foraminal) disc herniations with peridiscal osteophytes at the L2-L3 and L3-L4 levels.

5. Severe hypertrophic facetal arthropathy with ligamentum flavum hypertrophy at the L4-L5 and L5-S1 levels

6. Congenitally short lumbar vertebrae in their antero-posterior dimensions.